Self Referral Form

938 Mezzanine Dr Ste. B Lafayette, IN, 47905
765-742-1533

Are you a mother in need of support? Please submit this form and someone from the ĒMA Team will contact you within 24-48 hours.

Known Child Welfare Involvement? (Please check all that apply)
	I have an assigned Case Manager and is working on a reunification plan with Child Welfare Authorities. (Only check if you have a current court order)
	My child(ren) are living out of the home with a relative or non-relative
	I have an open investigation and children are at-risk of being removed from my care
	Domestic Violence
	Mental Health
	Substance Abuse
	No Support in Place

Someone from the ĒMA team will follow up to schedule an intake and assessment. How would you like to complete our intake and assessment process? Select your preference:

Help, Feedback, or Report Issue

Self Referral Form

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